Copy A For Social Security Administration — Send this entire page with
Form W-3 to the Social Security Administration; photocopies are not acceptable.

18 Local wages, tips, etc.

19 Local income tax

20 Locality name

Department of the Treasury—Internal Revenue Service
For Privacy Act and Paperwork Reduction
Act Notice, see the separate instructions.

Do Not Cut, Fold, or Staple Forms on This Page

Cat. No. 10134D

22222

a Employee’s social security number

OMB No. 1545-0008

b Employer identification number (EIN)

1 Wages, tips, other compensation

2 Federal income tax withheld

c Employer’s name, address, and ZIP code

3 Social security wages

4 Social security tax withheld

5 Medicare wages and tips

6 Medicare tax withheld

7 Social security tips

8 Allocated tips

9 Verification code

d Control number
e Employee’s first name and initial

10 Dependent care benefits

Suff. 11 Nonqualified plans

Last name

13

Statutory
employee

Retirement
plan

12a
C
o
d
e

Third-party
sick pay

14 Other

12b
C
o
d
e

12c
C
o
d
e

12d
C
o
d
e

f Employee’s address and ZIP code
15 State

Form

Employer’s state ID number

W-2

16 State wages, tips, etc.

Wage and Tax
Statement

Copy 1—For State, City, or Local Tax Department

17 State income tax

2017

18 Local wages, tips, etc.

19 Local income tax

20 Locality name

Department of the Treasury—Internal Revenue Service

a Employee’s social security number
OMB No. 1545-0008

Safe, accurate,
FAST! Use

Visit the IRS website at
www.irs.gov/efile

b Employer identification number (EIN)

1 Wages, tips, other compensation

2 Federal income tax withheld

c Employer’s name, address, and ZIP code

3 Social security wages

4 Social security tax withheld

5 Medicare wages and tips

6 Medicare tax withheld

7 Social security tips

8 Allocated tips

9 Verification code

d Control number
e Employee’s first name and initial

10 Dependent care benefits

Suff. 11 Nonqualified plans

Last name

13

Statutory
employee

Retirement
plan

12a See instructions for box 12
C
o
d
e

Third-party
sick pay

12b
C
o
d
e

12c

14 Other

C
o
d
e

12d
C
o
d
e

f Employee’s address and ZIP code
15 State

Form

Employer’s state ID number

W-2

Wage and Tax
Statement

16 State wages, tips, etc.

17 State income tax

2017

Copy B—To Be Filed With Employee’s FEDERAL Tax Return.
This information is being furnished to the Internal Revenue Service.

18 Local wages, tips, etc.

19 Local income tax

20 Locality name

Department of the Treasury—Internal Revenue Service

b Employer identification number (EIN)

This information is being furnished to the Internal Revenue Service. If you
are required to file a tax return, a negligence penalty or other sanction
may be imposed on you if this income is taxable and you fail to report it.
1 Wages, tips, other compensation
2 Federal income tax withheld

c Employer’s name, address, and ZIP code

3 Social security wages

4 Social security tax withheld

5 Medicare wages and tips

6 Medicare tax withheld

7 Social security tips

8 Allocated tips

a Employee’s social security number

OMB No. 1545-0008

9 Verification code

d Control number
e Employee’s first name and initial

10 Dependent care benefits

Suff. 11 Nonqualified plans

Last name

13

Statutory
employee

Retirement
plan

12a See instructions for box 12
C
o
d
e

Third-party
sick pay

14 Other

12b
C
o
d
e

12c
C
o
d
e

12d
C
o
d
e

f Employee’s address and ZIP code
15 State

Form

Employer’s state ID number

W-2

16 State wages, tips, etc.

Wage and Tax
Statement

Copy C—For EMPLOYEE’S RECORDS (See Notice to
Employee on the back of Copy B.)

17 State income tax

2017

18 Local wages, tips, etc.

19 Local income tax

20 Locality name

Department of the Treasury—Internal Revenue Service
Safe, accurate,
FAST! Use

a Employee’s social security number
OMB No. 1545-0008
b Employer identification number (EIN)

1 Wages, tips, other compensation

2 Federal income tax withheld

c Employer’s name, address, and ZIP code

3 Social security wages

4 Social security tax withheld

5 Medicare wages and tips

6 Medicare tax withheld

7 Social security tips

8 Allocated tips

9 Verification code

d Control number
e Employee’s first name and initial

10 Dependent care benefits

Suff. 11 Nonqualified plans

Last name

13

Statutory
employee

Retirement
plan

12a
C
o
d
e

Third-party
sick pay

14 Other

12b
C
o
d
e

12c
C
o
d
e

12d
C
o
d
e

f Employee’s address and ZIP code
15 State

Form

Employer’s state ID number

W-2

16 State wages, tips, etc.

Wage and Tax
Statement

Copy 2—To Be Filed With Employee’s State, City, or Local
Income Tax Return